Comparison of Myofascial Release, Muscle Energy Technique and Cervical Manual Therapy in Postural Neck Pain

Asian Journal of Orthopaedic Research

2(2): 1-6, 2019; Article no.AJORR.49803

Adarsh Ashok1, M. Suganya1 and B. Arun1*

1KG College of Physiotherapy, The Tamil Nadu Dr. M.G.R. Medical University, KG ISL Campus, Coimbatore, Tamil Nadu, India.

Authors’ contributions

This work was carried out in collaboration among all authors. Author BA designed the study, performed the statistical analysis, wrote the protocol and wrote the first draft of the manuscript. Authors AA and MS conducted review search, collected data, implemented treatment protocols. All the authors read and approved the final manuscript.

Article Information

Editor(s): (1) Dr. Ikem, Innocent Chiedu, Professor, Department of Orthopaedic Surgery and Traumatology, Obafemi Awolowo University, Ile-Ife, Nigeria. Reviewers: (1) Vijaya Krishnan, MGM College of Physiotherapy, India. (2) K. Ramesh Kumar, S. V. S. Medical College, India. Complete Peer review History: http://www.sdiarticle3.com/review-history/49803

Received 02 April 2019 Original Research Article Accepted 19 June 2019 Published 26 June 2019

ABSTRACT

Globally neck pain has become common health problem in younger generations. Neck pain occurs due to various pathological reasons. Even though there is variety of management protocols to alleviate the neck pain, their efficacy is still not clear. This study includes three different perspectives of manual therapy technique on the postural neck pain. This study is a single blinded randomized controlled trial. 81 volunteers with postural neck pain were selected randomly. They all underwent various evaluation procedures by a blinded assessor. All the participants were divided into three groups with 27 volunteer in each. Group I underwent Myofascial release therapy (MFRG), Group II underwent Muscle energy technique (METG) and Group III underwent Cervical manual therapy (CMTG). All the treatment underwent for 8 weeks duration and their lateral flexion range of motion, disability and proprioception were measured using goniometer, neck disability index and repositioning error. The result of the study analyzed through SPSS 20.0, it shows that there was no significant difference between the groups in post treatment values, F value for the range of motion is 4.70, Disability is 0.11 and proprioception is 8.71. So this study concluded that there was no difference in improvement of variables following all three modalities. ______

*Corresponding author: Email: [email protected], [email protected];

Ashok et al.; AJORR, 2(2): 1-6, 2019; Article no.AJORR.49803

Keywords: Myofascial release therapy; Maitland mobilization; muscle energy technique; disability; proprioception.

1. INTRODUCTION manual therapy [12]. Although there are variety of methods in the manual therapy but none of the Neck pain is one of the common problems techniques were identified as the best. There are among working population. It has become a still inconclusive evidences exist on the selection major health problem in personal health and of which type of manual therapy effects on overall wellbeing of the public [1]. Multiple chronic neck pain. This study tries to identify the pathologies were identified as a causative factor effectiveness between the three common manual for the neck pain and one of the common factors therapy techniques on disability, range of motion noted in recent years is poor posture. and repositioning error. Occurrence of pain may due to interference of the surrounding tissues around the neck due to 2. METHODOLOGY poor postural habits [2]. When the head is pronounced forward, Muscles around the neck The study was accepted by Institutional ethical were forced to abnormally stretched position committee KG Hospital and post graduate which predispose to pain [3]. Studies identified medical institute. Single blinded randomized that there was a strong association between controlled trail. Notice about the neck pain study cervical postural adaptation, with neck pain and was displayed in the Outpatient department of disability [4], alteration in the posture can also KG College, KG Campus and KG Hospital. affects the range of motion of the cervical spine Those who volunteer are registered and an [5]. appointment was given for the assessment. A separate assessor who is not involved in the Acute neck pain would cause early muscle study assessed all the registered volunteers and weakness which is the contributing factor for the identifies the eligible participants and sends to persistent (chronic) neck pain. Abnormal loading the second evaluation process. 154 participants in the muscles occurs due to poor posture, which were evaluated in the first round from them 112 may pronounce neck instability [6]. Although were sent to the second round. Based on the there are multiple reasons identified for neck selection criteria 94 were eligible for the study pain, poor posture is where the muscles were and all were randomly assigned into three failed to stabilize the neck. Imbalance in the groups, randomization was done for the eligible muscles results in movement dysfunction which participants using a computer generated random directly effect on joint surface lead to early sequence table by a blinded assessor. The first degenerations. These changes are the direct treatment session was provided to each patient source of pain in the neck and this in-turn result on the same day of the initial assessment. in muscle imbalances [7]. Muscle and the fascia Myofascial release group (MFRG) included 31 were interconnected; any fascial tightness may participants, 32 participants in Muscle energy result in tightness of the muscle and vice versa. technique group (METG) and 31 were included in Tightness in the myofascial are due to overuse or the Cervical Manual therapy group (CMTG). trauma to the muscles which support the Sudden dropout was found in all the groups, shoulders and neck [8] usually the myofascial there were 13 participants withdrawn from the pain presents with deep aching sensations which study due to personal reasons. So this study are like tightness or stiffness at the neck [9]. ended with 27 subjects in each group. Participants are with 25-45 years of age group, One of the identifiable causes for the neck pain complains of neck pain more than 7 weeks, was due to positional fault in the cervical clinically diagnosed as mechanical neck pain, vertebra, abnormal movements in the neck due neck pain without any radiating symptoms, pain to muscle weakness which cause the scale not more than 6 in visual analog scale, only biomechanical changes in the cervical spine restricted lateral movement was identified using results in restriction of the joint [10]. Reduction in movement testing. Participants with radiating the range of motion, neck muscle strength and pain, severe pain and any symptoms of reduce endurance would be the common weakness and neck pain due to systemic features in the chronic neck pain [11]. involvement are not included. All the testing procedures were completely explained and Physiotherapy management for neck pain written informed consent was obtained from all includes electrotherapy modalities, exercises and the participants before the initiation of the study.

Ashok et al.; AJORR, 2(2): 1-6, 2019; Article no.AJORR.49803

The study was conducted for 8 weeks and the analyze the significance between the groups. measurements were taken for evaluation. MFRG When the Anova is significant then post hoc tests received a set of fascia release techniques will be used to analyze. The significant level was described by Manheim 2008 [13], the participant set at α equal to 0.05. in prone lying and apply unilateral and bilateral gross stretch of the upper trapezius. In addition Table 1 presents the baseline demographic muscle release technique were applied using characteristics of the subjects. No significant cross hand release of the lateral neck, cross differences were found between the groups on hand release of the anterior cervical spine. Gross the baseline level. Study includes 26% of stretch under the occiput which stretches the participants with the age of 25 years to 28 years suboccipital muscles. Stretch was hold for 90 and least in 16% of participants in 41years to 45 seconds and until release and repeat again, the years. Most of the person who has longer release sequence was repeated until end feel symptoms works for longer duration, 56% works was reached. METG received a set of exercises for 8 hours of work whereas 18% of participants described in Gupta et al. 2008 [14], patient was works more than 10 hours. 35% of participant’s positioned comfortably in sitting position, the complaints of 1-2 yrs of duration and more than 6 therapist stood behind the patient, hand should years only 12% complain of pain. Questions be placed on the side of the patient head and related to physical activity 38% participants then take the agonist muscle to the barrier of answered activity which was less than 30 tension and maintain in the position, ask the minutes and only 11% answered for more than patient to resist the movement and produce 120 minutes. Pain measurement of the contraction of the agonist muscle which is 20% of participants with less than 5 in visual analog the strength for 7—10 seconds. Make the patient scale marked with a ruler was 62% and more relaxes for 5 seconds, repeat the movement in than 5 was 38%. the newly restricted barrier with a gentle stretch without pain holds for 10—30 seconds and Table 2 presents the ANOVA analysis for the repeat for 5—7 times. CMTG received unilateral three variables. Post test were taken for the PA glide on the symptomatic side which was analysis and the result shows that range of explained by Kanlayanaphotporn et al. 2009 [15]. motion of the cervical spine is F 4.70 which is not Participants were lay prone and the significant to the table value and the probability physiotherapist stood at the head end of the of this result assumes the null hypothesis at 0.95. patient. Therapist keeps the thumb at the level of The result of Proprioception of the cervical spine the facet of the selected hypomobile cervical is F 8.71 which is not significant to the table vertebra and applied an unilateral PA oscillatory value and the probability of this result assumes pressure using Grade I and Grade II initially and the null hypothesis at 0.99. The result of followed by Grade III Maitland manual therapy Disability of the cervical spine is F 0.1097 which protocol. The oscillatory movement was is not significant to the table value and the performed at a frequency of 2Hz for 2 mins and probability of this result assumes the null repeated for 5 times. The rest time between each hypothesis at 0.90. Since the Anova analysis mobilization is 2 mins. Data were collected by a shows no significant difference in the values this separate assessor to prevent bias. Disability was study accepts null hypothesis. The study shows measured using Neck disability index, Lateral that there is no significant difference obtained flexion range of motion measured using between the groups. goniometry and proprioception of neck was measured using repositioning error. All the Neck pain is a common musculoskeletal disorder collected data were analyzed using inferential in modern times. Causative factors of neck pain statistics by SPSS 20.0. were poorly defined. Neck pain as consequences of weakness of the muscles, fibrous contractures 3. RESULTS AND DISCUSSION in the joint structures, and spasm over the muscles which show the way to early fatigability A detailed analysis was conducted using SPSS of muscles and restricted range of motion. These 20.0. Three variables were calculated using a macro changes alter the whole neck function blinded assessor and the variables were which results in functional disability of neck. analyzed. The details of the variables were measured in the beginning of the study (pre test) Myofascial release therapy is one of the passive and at the end of the study (post test). Since the therapies which would reduce the fascial study involves three groups ANOVA was used to tightness and bring back the normal movement in

Ashok et al.; AJORR, 2(2): 1-6, 2019; Article no.AJORR.49803

the fascia [16]. It has played a major role on mechanoreceptors which involve centrally reduction of pain since it alters the matrix mediated pathways including periaqueductal viscosity of the fascia and converts it from solid gray matter in midbrain and noradrenergic plays to liquid and removes pressure of fascia from the a major role in descending inhibitory pathways. pain sensitive structures and causes realignment MET increases range of motion since the muscle of the fascial structures [17]. It also plays a major extensibility is increased in around neck pain and role in stretching the capsule and cause there is a reflex relaxation and viscoelastic sympathetic stimulation by somatic efferent and changes which could cause change in the stretch local activation of periaqueductal gray matter tolerance [20]. which plays the role of descending modulations [13]. It is assumed that pain reduction which Joint mobilization has potential benefit in automatically improves the functions, and the reducing pain, disability and range of motion in neck pain which impact on the movement control chronic neck pain. Joint mobilization would play a and functional deficits. Removing the role on pain reduction by the mechanism of impairments existing in tissues and reducing the neurophysiological mechanisms which have restrictions can consequently improve the range been found to produce hypoalgesia following of motion, reduction in tissue tension and mobilization [21]. Pain relief by the mobilization is stiffness [18]. due to altered inputs from the higher centers. Pain reduction could improve the mobility in the Muscle energy technique is an active method of cervical region as well as the disability reduces voluntary contraction of muscle against the [11]. Joint Mobilization promotes activation counterforce of the movement [19]. Mechanism of the mechanoreceptors which improves the of the MET’s on pain reduction and activity awareness of the position sense and movement improvement are clearly unknown, but various sense in the neck [21]. hypothesis suggest that muscle and joint

Table 1. Demographic variables

Baseline characteristics Mean S.D p value Age MFRG 33.22 5.80 0.000 METG 34.01 6.24 CMTG 34.18 6.27 Duration of the MFRG 31.74 5.40 0.000 symptoms METG 34.67 5.85 CMTG 34.97 6.52 Hours of MFRG 33.37 6.08 0.000 Work METG 34.41 6.49 CMTG 33.59 5.73 Physical activity MFRG 33.37 6.99 0.000 METG 34.96 5.16 CMTG 33.04 5.91 Pain scores MFRG 4.93 0.73 0.000 METG 4.86 0.718 CMTG 4.96 0.808

Table 2. Measurement variables

ROM Proprioception Disability Source of Between Error Source of Between Error Source of Between Error variation variation variation Sum of 1.407 1167 Sum of 2.963 13.26 Sum of 1.284 456.4 Square Square Square Mean 0.7037 Mean 1.4815 Mean 0.642 Squares Squares Squares F value 4.7015 F value 8.715 F value 0.1097 (p<0.05) (p<0.05) (p<0.05)

Ashok et al.; AJORR, 2(2): 1-6, 2019; Article no.AJORR.49803

Current study would not support any of the 2. Yong Hong Cheng, Gui Cheng Huang. manual therapy techniques used in this study, Efficacy of massage therapy on pain and since all the groups show equal amount of dysfunction in patients with neck pain: A improvement there is no notable superior effect. systematic review and meta-analysis. In manual therapy group there would be a slight Evidence-Based Complementary and increase on proprioception when compared with Alternative Medicine. 2014;Article ID the other groups. There were a few limitations in 204360:13. this present study, first the participants were 3. Rodríguez-Huguet M, Gil-Salú JL, selected voluntarily and they all were using Rodríguez-Huguet P, Cabrera-Afonso JR, computer for daily work. They are not Lomas-Vega R. Effects of Myofascial representing any major group of populations. release on pressure pain thresholds in Second, the participants were recruited in a patients with neck pain: A single-blind single setup which has lack of demographic and randomized controlled trial. Am J Phys clinical characteristics. Third the Goniometer was Med Rehabil. 2018;97(1):16-22. used to measure cervical ROM which is not the 4. Yip CH, Chiu TT, Poon AT. The relationship most valid and reliable way to measure cervical between head posture and severity and ROM. Finally there is no pure control group used disability of patients with neck pain. Man in the study to identify the differences in the Ther. 2008;13:148–54. effect of the groups. 5. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML. Forward head posture 4. CONCLUSION and neck mobility in chronic tension-type headache: A blinded, controlled study. All the three groups showed no improvement on Cephalalgia. 2006;26:314–9. all the outcomes measured from the baseline to 6. Jull G, Trott P, Potter H, Zito G, Niere K, post treatment. The study concluded that Shirley D, Emberson J, Marschner I, application of all techniques provides same result Richardson C. A randomized controlled in range of motion, and functional disability but trial of exercise and manipulative therapy there was a significant improvement in the for cervicogenic headache. Spine (Phila Pa proprioception on manual therapy group when 1976). 2002;27(17):1835-43. compared with the other groups. 7. Sharan D, Manjula M, Urmi D, Ajeesh P. Effect of yoga on the Myofascial Pain CONSENT Syndrome of neck. Int J Yoga. 2014;7(1): 54-9. All the testing procedures were completely 8. Fernández-de-Las-Peñas C, Simons D, explained and written informed consent was Cuadrado ML, Pareja J. The role of obtained from all the participants before the myofascial triggers points in musculo- initiation of the study. skeletal pain syndromes of the head and neck. Curr Pain Headache Rep. 2007; ETHICAL APPROVAL 11(5):365-72. 9. Chaitow L. Muscle energy techniques (3rd The study was accepted by Institutional ethical ed.), Churchill Livingstone, Edinburgh. committee KG Hospital and post graduate 2008;185–7. medical institute. Single blinded randomized 10. Buyukturan O, Buyukturan B, Sas S, controlled trail. Karartı C, Ceylan İ. The effect of mulligan mobilization technique in older adults with COMPETING INTERESTS neck pain: A randomized controlled, double-blind study. Pain Res Manag. 2018; Authors have declared that no competing 285:63-75. interests exist. 11. Lee H, Nicholson LL, Adams RD. Neck muscle endurance, self-report, and range REFERENCES of motion data from subjects with treated and untreated neck pain. J. Manip. Physiol. 1. Fejer R, Kyvik KO, Hartvigsen J. The Ther. 2005;28:25-32. prevalence of neck pain in the world 12. Picavet HS, Schouten JS. Musculoskeletal population: A systematic critical review of pain in The Netherlands: Prevalence’s, the literature. Eur Spine J. 2005;15(6):834- consequences and risk groups, the 48. DMC(3)-study. Pain. 2003;102:167-178.

Ashok et al.; AJORR, 2(2): 1-6, 2019; Article no.AJORR.49803

13. Manheim CJ. The myofascial release compression in the treatment of myofascial manual. charlesten SC: Slack Incorporated. trigger points of the upper trapezius 2008;40(3):98-101. muscle. 2002;34-46. 14. Gupta S, Jaiswal P, Chhabra D. A 18. Fryer G, Fossum C. Therapeutic comparative study between post-isometric mechanisms underlying muscle energy relaxation and isometric exercises in non- approaches. In: Fernandez-de-las-Penas specific neck pain. Journal of Exercise C, Arendt-Nielsen Lars, Gerwin RD Science and Physiotherapy. 2008;4:88-94. editor(s). Sudbury MA: Jones and Bartlett 15. Kanlayanaphotporn R, Chiradejnant A, Publishers; 2008. Vachalathiti R. Immediate effects of the 19. Fryer G, Ruszkowski W. The influence of central posteroanterior mobilization techni- contraction duration in muscle energy que on pain and range of motion in technique applied to the atlanto-axial joint. patients with mechanical neck pain. Journal of Osteopathic Medicine. 2004; Disability and rehabilitation 2010;32(8): 7(2):79-84. 622-8. 20. Fryer Gary. Muscle energy technique: An 16. Nitsure P, Welling A. Effect of gross evidence-informed approach. International myofascial release of upper limb and neck Journal of Osteopathic Medicine. 2011; on pain and function in subjects with 14:3-9. mechanical neck pain with upper limb 21. Bialosky JE, Bishop MD, Price DD, radiculapathy- A clinicaltrial. Int J Dent Robinson ME, George SZ. The mechanisms Med Res. 2014;1(3):8-16. of manual therapy in the treatment of 17. Richard Shacksnovis. Effectiveness of musculoskeletal pain: A comprehensive myofascial manipulation versus Ischaemic model. Man. Ther. 2009;14:531-538.

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